ICF/IID Forms

HHSC does not require providers to use the sample forms listed below. A provider can use these sample forms as they are, modify the forms to fit a facility's needs or elect to create its own forms.

• Form 8005 ICF/IID Nursing Supervision For Unlicensed Assistive Personnel (UAP)
• Form 8006 ICF/IID Comprehensive Nursing Assessment
• Form 8007 ICF/IID RN Delegation Worksheet for 22 TAC §22
• Form 8008 ICF/IID Nursing Special Needs: RN Delegation and Care Instructions for Assistive Personnel
• Form 8009 ICF/IID Review of Comprehensive Nursing Assessment by RN
• Form 8010 ICF/IID Verification of Delegated Tasks to Unlicensed Personnel and Medication Administration by Unlicensed Personnel